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Welcome to one of the most powerful treatment modalities available to treat complex mental health and substance abuse issues.
Dialectical Behavior Therapy (DBT)
“Dialectic” means tension between two things that seem opposite but co-exist. Examples we all experience include the need to be social and the need for space, and the need to share and the need to keep private.
The underlying idea of dialectical behavior therapy (DBT) is working with this tension: both acceptance of the individual as-is, and working toward change. DBT takes the approach that because reality is all interconnected, has opposing forces, and is always changing, opposing views can simultaneously coexist.
One example is “I want to be sober” and also “I want to keep using”. These tensions do coexist, and also bring internal conflict. The conflict may be needed to catalyze change.
The main tension or dialectic in DBT is between acceptance and change. In session, DBT therapists work with individuals to teach skills to change behavior while also teaching methods for accepting the current self and current reality.
Dialectical behavior therapy is a talking therapy. It is one treatment modality under the larger umbrella of cognitive behavioral therapy (CBT). At its core, DBT is an evidence-based cognitive behavior therapy that integrates acceptance, dialectics, and mindfulness.
Dialectical behavior therapy is founded on the principle that individuals struggling with emotional dysregulation tend to experience intense internal conflicts. As a result, these individuals benefit from an approach that both validates their experiences while also facilitating change.
The difference with this modality of treatment from the others is that it is acceptance-based. In therapy sessions, the individual learns to accept the self as an individual having intense emotions, and at the same time, strengthens emotion regulation skills.
The aim of DBT has always been to build a “life worth living”. To this end, managing distress and developing greater emotional management factor in greatly.
Since Linehan introduced this treatment in 1987, the treatment has been applied to treat many complex and very challenging mental health conditions. Addiction is often a complex condition involving multiple co-occurring mental health conditions and often suicidality. Thus, DBT is an appropriate – and extremely powerful – therapeutic modality in these kinds of cases.
Dialectical behavior therapy emerged in the 1980s because therapists were looking for a standard behavioral therapy application to treat highly suicidal individuals. Existing methods of psychiatry, psychotherapy and even cognitive behavioral therapy were not working. In the early 1980s, Marsha Linehan and other clinicians combined what they knew from social learning theory and behavioral principles and applied that to individuals with suicidal behaviors. It was a trial-and-error process. The first randomized controlled trial involved the most severe, highly suicidal patients from local area hospitals who also met criteria for borderline personality disorder (BPD), a population known for suicide risk.
Ultimately, a new set of client targets emerged that focused on teaching patients:
1. Radical acceptance of everything each individual needs to accept: our past, present, and realistic future limitations;Radical acceptance of everything each individual needs to accept: our past, present, and realistic future limitations; and
2. New skills for distress tolerance and emotional regulation without impulsivity or destructively reducing the distress
Dialectical behavior therapy was developed to treat clients with complex, multiple, high-risk disorders. Its primary usage was for individuals with suicidal thoughts, suicidal ideation, suicidal behavior, and those with suicide attempts. Its effectiveness lies in flexibility rather than a highly structured approach. The engagement of a consultation team of mental health professionals helps with efficacy of treatment.
Dialectical behavior therapy is always used in treatment of borderline personality disorder (BPD), as this therapeutic modality has been found quite effective in helping individuals with this condition live happier, more productive and fulfilling lives.
The range of disorders DBT helps treat is vast. Substance abuse, eating disorders such as bulimia or binge eating disorders, other types of addictions, and symptoms of post-traumatic stress disorder can be treated with DBT.
Individuals prone to self-injury, various forms of self-harm, and other self-destructive behaviors tend to benefit greatly from this evidence-based treatment modality. DBT has also been demonstrated as an effective treatment for adolescents, addressing the range of challenges adolescents have to face: anxiety, depression, anger, impulsivity, and more.
Dialectical behavior therapy has been adapted for substance use disorder. In this adaptation, clinicians have added a new set of skills addressing drug addiction. They put these skills in the distress tolerance module of the DBT approach. These added skills emphasize community reinforcement, alternative rebellion, and other skills relevant to the addiction and substance use disorder scenario.
The underlying premise of DBT with regard to borderline personality disorder (BPD) is first of all that the main element of BPD is emotional dysregulation. This is an individual’s inability to regulate emotions within normal ranges. This results over time from a combination of biology and environment: It is a dysfunctional emotional regulation system in the individual’s biology coupled with an environment characterized by invalidation. An invalidating environment is one that regularly invalidates an individual’s communication of internal experiences, emotions included.
This lack of validation of emotions occurs when an individual attempts self-expression of private emotional experiences, but such expression is not tolerated by important others in the individual’s environment. For example, the child is upset and wishes to share an experience of feeling lonely or humiliated, and the parent scolds the child for feeling that way. Also, an individual’s emotional expressions may be ignored or invalidated until they reach a level high enough that the individual gets attention.
In this case, the individual learns, often subconsciously, that effective communication requires intense emotional expression.
Further, the invalidating environment does not model or teach effective skills for emotional regulation, so the individual does not learn to understand, tolerate, label, or regulate emotional experiences. The invalidating environment also catalyzes a negative spiral: the more emotional the individual is, the greater the likelihood of receiving invalidation in the environment, in turn leading to greater emotionality.
This combination of elements, emotional dysregulation at the biological level coupled with an invalidating environment, can lead to borderline personality disorder, which is characterized primarily by emotional dysregulation. Dialectical behavior therapy is designed to treat these kinds of mental health issues.
Part of DBT treatment focuses on skills training. This is to develop stronger coping skills. In DBT skills training, patients learn behaviors that can be used in place of ineffective or maladaptive behaviors. The fundamental emphasis is on acquiring and strengthening skills. The skills are divided into modules. There are four skills modules in DBT:
One of DBT’s core pillars is developing mindfulness – the practice of cultivating non-judgmental awareness of the present moment. These skills help individuals learn to observe and accept their emotions, thoughts, and sensations without judgment or impulsive reaction. While mindfulness is itself a core pillar within the DBT practice, it also forms the foundation for the other DBT skills. Mindfulness helps support the cultivation of greater self-awareness and emotional regulation.
Emotional well-being relies in part on healthy relationships. Individuals with emotional dysregulation challenges also have relationship challenges because by their very nature, human interactions are often distressing. The distress triggers a cascade of difficult and uncomfortable sentiment involving that other person. These are not easy conditions for a relationship to build or thrive.
Those with emotional dysregulation challenges struggle to understand, identify, and effectively manage their emotions and emotional expressions. Since overcoming this challenge is a primary aim for DBT, the therapy teaches emotion regulation skills. This includes identifying and labeling emotions, understanding the functions and purpose of human emotions, and modulating intensity of emotional experience and emotional expression. Since part of emotional regulation is biophysical – it has to do with how the brain responds to triggering stimuli and the specifics of neurotransmitter release into the blood stream – learning emotional regulation skills requires some focus to retrain your brain, literally. Developing greater emotional regulation skills helps individuals gain greater control over their behaviors and experiences, improving overall well-being.
The ability to tolerate distress is hampered in some individuals. This often accompanies emotional dysregulation challenges. The impulse is to destroy the distressor rather than a willingness to hear and address the actual issue. Emotions quickly become overwhelming. Another important pillar of DBT, distress tolerance skill-building emphasizes the importance of building skills to cope with crises and overwhelming emotions effectively. Techniques include self-soothing activities, mindfulness of breath, and crisis survival strategies. These help equip the individual with the necessary tools to navigate distressing situations without resorting to destructive behaviors. As individuals learn to tolerate distress without making it worse, they gain a greater sense of mastery and resilience. Confidence improves. This is the healing work.
All efforts work to improve general coping skills and patient quality of life. Addressing interpersonal deficits and emotional dysregulation are “change skills”, while building mindfulness skills and distress tolerance are “acceptance skills”.
Dialectical behavior therapy is conducted in individual therapy sessions, skills training in group therapy sessions, and clinician consultation team meetings. Depending on the situation, phone coaching may also be available for DBT in some clinics.
Mindfulness is central to DBT. Mindfulness skills are considered “core” skills in this approach. Each skills module has at least one mindfulness skill included within it. These may include mindfulness of others in interpersonal skills development, mindfulness of current emotions in strengthening emotional regulation, and mindfulness of current thoughts in addressing distress tolerance.
At Premiere Recovery Center, located in Happy Valley, Oregon, we incorporate DBT quite often into individuals’ customized treatment plans. It is an effective technique for treating even the most complex cases of substance use disorder along with co-occurring mental health issues.
Substance addictions often arrive accompanied with emotional regulation challenges. Not to worry. This is precisely what we’re here for.
We have many qualified clinicians on staff that offer treatment of DBT. Several of these mental health professionals work together on each patient’s progress, in line with the rudiments of the modality.
As long as patients are ambulatory (Levels of care 2.1 and 2.5), all are welcome in our facility. We specialize in treating substance use disorders and addiction disorders. As these disorders are often accompanied by complex mental health challenges, DBT is a standard in our facility.
We offer local housing to our patients undergoing treatment. This option helps our patients stay in the treatment frame of mind 24/7, helping them gain from extended immersion in the healing environment. For our patients undergoing dialectical behavior therapy, where emotions can be intense and perhaps easily triggered, an extension of treatment in one of our luxury local homes may be the perfect solution.
Transitional housing is also an option for when individuals reach that level of growth and healing. We are affiliated with Premiere Sober Living, a transitional housing facility. Our residents enjoy the comfort of continued clean-and-sober support 24/7.
Not everyone needs nor would benefit from DBT. But for those struggling with emotional regulation, regardless of the cause or the precise mental health condition of which it is a part, this therapy is going to help.
If you see yourself or a loved one explained on this page, we can help. Give us a call today, and we will get you started with a treatment strategy that’s right for your situation. Let us help.
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